Was the Government right to scrap the 18-week waiting time target?

9 July 2010

Dr Jonathan Steel says the 18-week target is not primarily responsible for the reduction in waits, and has had serious unintended consequences. But Dr Jennifer Dixon argues the 18-week target is a vital safeguard, and that its removal may send waiting times creeping back up.

Dr Jonathan Steel says the 18-week target is not primarily responsible for the reduction in waits, and has had serious unintended consequences. But Dr Jennifer Dixon argues the 18-week target is a vital safeguard, and that its removal may send waiting times creeping back up.

I've been a GP long enough to remember the days of 18-month to two-year waits for hip replacements. And while the reduction to a maximum 18-week wait from referral to treatment is a truly great achievement, it's important to realise this isn't simply an achievement of the target.

The past decade has seen a 95% increase in NHS funding in real terms. The number of hospital consultants has almost doubled, from 19,500 in 1995 to 37,000 in 2009, and there has been a significant increase in operating theatre capacity through a hospital building programme and use of independent providers. Post-operative stays are shorter, increasing hospital capacity even further.

This massive increase in supply is the real reason why waiting times have come down and taxpayers should expect nothing less.

While a reduction to 18 weeks' wait has been a success, it has not been without its unintended consequences from a clinician's point of view. Clinical priorities have been distorted, such as putting large-volume, simple procedures like cataracts ahead of more complex and painful conditions like back surgery.

Patients themselves have also sometimes made it difficult to judge the success of the target. If it looks like the 18-week target is going to be missed, patients are offered an alternative provider. But most are loyal to their local hospital, refuse the alternative and are told to get a re-referral from their doctor.

For some patients, being seen and treated quickly is a high priority. For others the personal relationship that they have with their local hospital or ease of visiting is of greater importance.

As GPs we don't understand what happens in the bureaucratic black box of the 18-week pathway, but we do see confused patients with letters from the hospital telling them their appointments have been changed. I suspect this is sometimes a deliberate delaying tactic, to avoid over-performance against the 18-week target in some clinical areas while others struggle to hit it.

From 1 April 2010, the NHS constitution has enshrined the right for all patients to be treated within 18 weeks of GP referral. The coalition Government's amendment of the NHS operating framework has not changed that constitutional right, just the performance management of it.

So from the acute provider perspective, nothing much has changed – 18-week pathways are still required. Indeed with a more competitive provider market and widespread publication of statistical information, acute trusts will pride themselves on their access performance.

But we no longer need the army of bureaucrats in PCTs and SHAs to performance-manage these targets and redirect referrals around the system against patients' wishes. This will save a great deal of money and not adversely affect patient care. It may even improve it.

From a patient's perspective, there are certain advantages to not exercising the 18-week constitutional right. It is now possible to delay care and go on holiday or elsewhere without worrying about being sent back to the beginning, or to opt to be treated at the local hospital even if this takes longer.

An end to the performance-managed 18-week target reduces bureaucratic waste, resets clinical priorities and puts patients in charge of their care. I think that's a perfectly sensible decision.

Dr Jonathan Steel is a GP in Uley, Gloucestershire

The NHS is about to enter the toughest financial climate it has faced in its history – and it is doing this without one of the key performance-management tools it has had at its disposal in recent years.

That tool is the iconic 18-week waiting time target.

The Government's decision to move to outcome targets rather than process targets is, on the whole, welcome. But the 18-week target – backed up by strong performance management – has undoubtedly been the most effective way of reducing waiting times in the NHS in England.

Without this approach, waiting times would not have fallen so steeply. You only have to look at the relative performance of the four health systems of the UK – in crude productivity terms – to see that the impact is greatest in England where targets are tighter and performance management more robust.

Of course this is not a black and white situation and there is a subtlety at play that we need to keep in mind.

Targets are certainly not a panacea – too many can demotivate and have perverse effects locally, so only a few should be used.

And remember, the 18-week referrals target hasn't been removed altogether – it just won't be performance managed any longer.

Though, somewhat confusingly, the scaled-down four-hour A&E target will be performance managed, although it is not clear why this is singled out for different treatment.

The foundation trust regulator Monitor currently continues with assessment against national targets as part of its compliance framework. It will be interesting to see how the performance of NHS trusts on the 18-week wait will change compared with the performance of autonomous foundation trusts.

There is much to consider. But the obvious conclusion is that the Government is taking a surprising and somewhat risky approach by removing a proven performance-management tool for driving down waiting times – especially at a time when the NHS enters a period of significant financial constraint and will have to make efficiency savings of between £21bn and £30bn.

The revised operating framework will mean the NHS will now rely on two means of keeping waiting times down: commissioners through local contracting, and public reporting of waiting-times data.

But the NHS will be operating in a vastly different environment – PCTs are facing 30% cuts in administration budgets, and GP commissioners are significantly underdeveloped.

The worry is that these weaknesses will mean commissioners will be unable to keep the pressure on hospitals to maintain low waiting times.

NHS trusts and foundation trusts are facing similar cost pressures and faced with making tough financial savings. The worry is that providers will respond by allowing waiting times to rise, despite the health secretary's protestations that this should not happen.

We will now see how providers respond – but holding them to account for their waiting times will be vital.

I've no doubt that the move to outcome measures is the right approach in the long run. But waiting times for hospital appointments are a key part of how the public judges the NHS.

Given the miserable history of the NHS on this score, the 18-week wait should remain a firm target.

Dr Jennifer Dixon is director of the Nuffield Trust

Will waiting times start rising without the 18-week target? Will waiting times start rising without the 18-week target? Yes No